IBS Care Pathway - Updated January 2017

The IBS Care Pathway was launched in parallel with the Refractory IBS Service launched by Gloucestershire Hospitals NHS Foundation Trust (GHFT) in early 2016. It is designed to support GPs in providing best practice care to their IBS sufferers and to ensure that only appropriate patients are referred into the service. Referrals should only be made once the primary care options described have been exhausted.

In keeping with NICE DG11, faecal calprotectin testing was also commissioned by GCCG in early 2016 as a final screening test for patients under the age of 45years with unresponsive (refractory) IBS prior to referral into the new GHFT Refractory IBS Service.

This pathway has now subsequently been revised to reflect the expansion of the Refractory IBS service to those over 45 years of age, who have had previous investigation (within the last 5 years) which was negative and there has been no change in symptoms since. For those over the age of 45 who have not previously been investigated, referral to a gastroenterology consultant is indicated.

GHFT provide a service for those IBS sufferers who have failed to respond to the management laid out in this pathway in primary care.

This clinic is run by specialist dietitians and management is based around dietary manipulation, including the Low FODMAP approach, which has been shown to be highly effective for many of these patients. Non-responders will be referred on for further gastroenterological assessment.

Practice Point

Referrals into the service should only be made after following the assessment and management pathway laid out in this document and by using the dedicated form provided. Extensive tests such as colonoscopy are NOT required prior to referral, but will be instigated by the service if indicated.

FC is a protein biomarker which is shed by the intestinal mucosa in quantities which relate to the level of inflammation in inflammatory bowel conditions. This very sensitive marker has now been commissioned by the CCG for use by GP’s in patients with refractory IBS (under the age of 45yrs) whom the GP is considering referring into the new GHFT Refractory IBS Service. Please see the flowcharts below for details.

This resource pulls together a variety of advice sheets and links to help clinicians manage patients suffering from IBS in primary care, and to make referrals into secondary care when necessary.

IBS Care Pathway - Overview

Please click the relevant flowchart box to be taken directly to textual information.

Red Flags

Unintentional or unexplained weight loss

Rectal bleeding

Anaemia

Abdominal, pelvic or rectal mass

Raised inflammatory markers

Aged over 45: Family history of bowel or ovarian cancer

Aged over 50: women with symptoms suggestive of ovarian cancer

Aged over 60: a change in bowel habit lasting more than 6 weeks with looser and/or more frequent stools

Presentation

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder with no known organic cause. 5-10% of the population are affected, with sufferers being predominantly female with a peak incidence in the third or fourth decade of life. The average practice will have up to 100 such patients registered with them.

It is a symptom-based diagnosis characterised by chronic abdominal pain, bloating, wind and alteration of bowel habit. There may also be urgency of bowel movements, a feeling of incomplete evacuation (tenesmus), abdominal distension or upper GI symptoms such as nausea. In some cases, the symptoms are relieved by bowel movements. Pain may predominate.

The onset of IBS is more likely to occur after an infection or a stressful life event, but varies little with age.

IBS-D - Diarrhoea predominates

IBS-C - Constipation predominates

IBS-M - Both diarrhoea and constipation occur

IBS-U - Unclassifiable – does not fit into the above categories

Some authorities also use the following descriptions:

IBS-pain predominant - Pain predominates

IBS-PI - Post-infectious IBS which can take up to 18 months to resolve

If there are no red flag features (see above), attention to the exclusion of bowel or ovarian cancer and the consideration of a differential diagnosis, a positive diagnosis can usually be made on the basis of symptoms alone by applying the Rome Criteria (below).

However, formal exclusion of other conditions (see below) may also be considered appropriate.

Key Points

Suspect IBS in a person aged under 45 who reports any of the following symptoms for at least 3 months:

Abdominal pain or discomfort

Intermittent bloating

Change in bowel habit

Check for 'red flags' (above) and refer them to secondary care for further investigation if appropriate.

Consider diagnosing irritable bowel syndrome only if the person has:

Over 3 months of continuous or recurrent symptoms of abdominal pain or discomfort which is relieved by defaecation and/or is associated with a change in stool frequency with or without a change in stool consistency.

2. Two or more of the following, for at least 1 out of 4 occasions or days:

Altered stool consistency >3/day or <3/week

Altered stool form – showing the patient the Bristol Stool Scale can speed assessment and can help patients to discuss their stool consistency

Associated symptoms such as urge incontinence associated with irritable bladder, exacerbation with anxiety or stress and nausea are common and may support your diagnosis. Patients with fibromyalgia commonly suffer from IBS.

Practice Points

When establishing bowel habit, showing people the Bristol Stool Scale may help them with description, particularly when determining quality and quantity of stool.

People presenting with irritable bowel syndrome symptoms commonly report incomplete evacuation/rectal hypersensitivity, as well as urgency, which is increased in diarrhoea-predominant irritable bowel syndrome.

Only about 20% of people experiencing faecal incontinence disclose their incontinence and only if asked. People who present with symptoms of irritable bowel syndrome should be asked open questions to establish the presence of such symptoms (for example, 'tell me about how your symptoms affect aspects of your daily life, such as leaving the house').

Healthcare professionals should be sensitive to the cultural, ethnic and communication needs of people for whom English is not a first language or who may have cognitive and/or behavioural problems or disabilities. These factors should be taken into consideration to facilitate effective consultation.

In IBS, routine clinical tests must all be normal, although the bowels may be more sensitive to certain stimuli such as balloon insufflation testing.

Coeliac disease is an autoimmune disease affecting the small intestine which can cause abdominal pain, diarrhoea, steatorrhoea and failure to thrive in children. It can also cause chronic constipation, anaemia and fatigue, and can be asymptomatic. Partial villous atrophy causes malabsorption of nutrients, minerals and fat soluble vitamins (A, D, K and E), B12 and folic acid deficiency, iron deficiency, calcium and vitamin D deficiency.

Diagnosis is by detecting anti-transglutaminase (TTG) antibodies and confirmation is by jejunoscopy and biopsy which demonstrates partial atrophy of the small intestinal villi.

Diagnosis can be difficult and may be done by stool microscopy, stool giardia antigen ELISA testing and by detecting the flagellate organisms in small intestinal samples obtained by using a swallowed and retrieved gelatine capsule.

Treatment is with an imidazole antibiotic such as metronidazole.

In diagnosing IBS, inflammatory bowel diseases including Ulcerative Colitis and Crohn’s should be excluded by finding negative inflammatory markers including CRP, plasma viscosity and/or ESR. Faecal calprotectin is a very sensitive test for intestinal inflammation, but a request is only accepted from primary care in Gloucestershire for use in patients as a part of the decision leading to referral to the Refractory IBS Clinic, as outlined in this document.

Microscopic colitis is a less common form of inflammatory bowel disease which presents with peristent non-bloody watery diarrhoea which varies little in intensity. It tends to affect an older age group and is female predominant, but 25% of cases present under the age of 45. Due to its symptoms, it is reasonably easy to identify. Blood tests are usually normal although inflammatory markers can be raised and can also result in raised faecal calprotectin. The intestinal mucosa appears normal on direct visualisation, e.g. on colonoscopy, but characteristic inflammatory cells are found on histology (raised intraepithelial lymphocytes) predominantly on the right side of the colon. In 50% of cases the condition is self-limiting and resolves spontaneously. It is commonly linked to drugs such as NSAIDs, and treatment ranges from symptomatic control with loperamide to topical steroid treatment such as budesonide.

Bile salt malabsorption causes abdominal pain and diarrhoea.

Maintain a high level of suspicion for this condition if the patient has a history of cholecystectomy or of terminal ileal resection and Crohn’s disease. It can also be idiopathic primary bile acid malabsorption and may result from other gastrointestinal problems including small bowel bacterial overgrowth, radiation enteropathy, coeliac disease and chronic pancreatitis.

The gold standard for diagnosis is by radiolabelled bile salt absorption testing (SeHCAT) however this is not available in Gloucestershire. If clinical suspicion is high diagnosis is normally made by trial of treatment such as cholestyramine (Questran one-two sachets daily). Treatment is highly effective, although cholestyramine can be unpalatable and this can negatively affect compliance. A low fat diet is also recommended in addition to cholestyramine and can have a positive effect on symptoms

It is caused by a variety of gastrointestinal problems including small bowel fistulae, diverticula, surgical blind loops such as after bariatric surgery or Bilroth II antrectomy, ileo-caecal valve resection, gastroenteritis, overuse of proton pump inhibitor medication. Chronic pancreatitis, immunosuppressant medications, common variable immunodeficiency, IgA deficiency and hypogammaglobilinaemia can also cause SIBO.

Diagnosis can be made by the D-xylose absorption test or by hydrogen breath testing, but the gold standard is jejunal aspiration with the aspirate being found to grow in excess of 105 of bacteria per millilitre of fluid – this test is rarely performed however. Treatment is with antibiotics and prokinetic drugs, sometimes cyclically. If clinical suspicion is high, a trial of metronidazole 400mg PO tds for 5/7 is recommended and, if successful, negates the need for further investigation.

Pancreatic exocrine insufficiency (PEI) is a condition characterized by deficiency of the exocrine pancreatic enzymes, resulting in the inability to digest food properly, or maldigestion.

The exocrine pancreas produces 3 main types of enzymes: amylase, protease, and lipase. Under normal physiologic conditions, the enzymes (specifically, lipase) break undigested triglycerides into fatty acids and monoglycerides, which are then solubilized by bile salts. Because the exocrine pancreas retains a large reserve capacity for enzyme secretion, fat digestion is not clearly impaired until lipase output decreases to below 10% of the normal level.

The diagnosis of PEI is largely clinical. It may go undetected because the signs and symptoms are similar to those of IBS or because the signs and symptoms are not always evident, due to dietary restrictions such as adopting a low fat diet. Faecal elastase is a useful marker of PEI but false negatives are common. A trial of Creon 50,000U with meals and 25,000U with snacks is recommended if clinical suspicion is high (symptoms of diarrhoea, steatorrhoea and weight loss often associated with bloating and offensive stool/flatulence in a similar presentation to SIBO) followed by referral to gastroenterology for further investigation and follow up.

Management of PEI is based primarily on pancreatic enzyme replacement therapy but may also include lifestyle modifications and vitamin supplementation as appropriate.

Food allergy may cause generalised symptoms (pruritus, erythema, urticaria, angioedema, eczema, and rhinitis), but symptoms may be limited to the gastrointestinal tract. GI symptoms may include nausea, vomiting, bloating, pain, diarrhoea, and oedema of the lips and tongue. Most true food allergies occur in children, particularly infants, and over 90% of food allergies are caused by eggs, peanuts, milk, soy, nuts, shellfish, fish, or wheat.

Easily mistaken for IBS, dietary fructose malabsorption can cause bloating (from fermentation in the small and large intestine), diarrhoea and/or constipation, flatulence, heartburn, stomach pain (from muscle spasm which can vary from mild and chronic to acute but erratic), nausea, vomiting (on consumption of large quantities).

Diagnosis is by hydrogen breath test. Treatment is by exclusion of fructose from the diet.

CFAP is similar to but less common than IBS. The principal difference is the absence of any change in bowel habit, constipation or diarrhoea. Treatment includes low dose antidepressants.

CIC is diagnosed when constipation is present for at least a quarter of the time. It is similar to IBS-C (constipation predominant IBS), but does not have the other features of IBS.

People with IBS also suffer from a variety of functional disorders more commonly than other people, including:

Gloucestershire's Cancer Clinical Programme Group has agreed to deviate from NICE guidance in relation to the use of Faecal Occult Blood Tests (FOBTs) as it is no longer available to request in Gloucestershire. It is therefore recommended that GPs trust their clinical experience when deciding whether or not to refer symptomatic patients.

IBS

If patients conform to the IBS diagnostic criteria above, the following interventions should be trialled (see details under ‘GP Management’):

Refractory IBS

Patients who do not respond to these may be considered to have ‘refractory IBS’. These patients may benefit from referral to the Refractory IBS Service, after faecal calprotectin screening, or if previous investigation within the last 5 years has demonstrated no structural cause for symptoms, and there have been no change in symptoms since.

Key Point

NICE DG11 (2013): “Many people with irritable bowel syndrome have unnecessary invasive hospital investigations before their condition is diagnosed. Using faecal calprotectin testing will mean most people with irritable bowel syndrome will be diagnosed without the need for these investigations.”

This test is a very specific marker for lower GI inflammation and as such helps differentiate between inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS) in patients with relatively recent onset lower gastrointestinal symptoms once a decision has been made that cancer is not suspected (see guidance above). It is a 36kDa calcium and zinc binding protein which is resistant to enzymatic degradation and can be easily measured on faeces. Levels above 150µg/g suggest the existence of active IBD with a sensitivity of 100% and a specificity of 97%.

In keeping with DG11, faecal calprotectin testing has been commissioned by GCCG as a final screening test for patients under the age of 45years with unresponsive (refractory) IBS prior to referral into the new GHFT Refractory IBS Service. For those over the age of 45 who have not previously been investigated, referral to gastroenterology consultant is indicated. If previous investigation (within the last 5 years) has been undertaken, was negative and there has been no change in symptoms since investigation referral to the GHFT Refractory IBS Service may be appropriate.

Practice Point

Please do not request faecal calprotectin as a routine test for the diagnosis of IBS. Only consider it in primary care when deciding to refer to the Refractory IBS clinic.

Order the test via ICE, which will take you through a series of questions. Please note that:

Patients should not take any NSAID’s for four weeks prior to collecting a sample.

The sample should be collected on a day when it can be delivered to the GP surgery or the laboratory on the same or next day. Samples taking more than 3 days to reach the laboratory will not be analysed and a repeat sample requested.

The test result will be available within 14 days of sample receipt in the laboratory.

Drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas.

Restrict tea and coffee to 3 cups per day.

Reduce intake of alcohol and fizzy drinks – particularly “diet” drinks which contain sweeteners that can act as a laxative effect. Drinks such as cola are high in phosphoric acid which can exacerbate dyspeptic symptoms and carbonated drinks can cause increasing bloating and abdominal discomfort

Consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) in patients with predominant bloating and pain

Reduce intake of 'resistant starch' (starch that resists digestion in the small intestine and reaches the colon intact), often found in processed or re-cooked foods.

Review the person's fibre intake and adjust (usually reduce) according to symptoms.

Discourage intake of insoluble fibre (for example, bran fibre).

If more fibre is needed, recommend soluble fibre such as ispaghula powder, or foods high in soluble fibre (for example oats). A slow increase in fibre is recommended.

Ensure sufficient caffeine-free fluid (at least 2 litres/day).

Probiotics

If the person wants to try probiotics, advise them to take the dose recommended by the manufacturer for at least 4 weeks while monitoring the effect. VSL#3 and Symprove have limited evidence to support their use in IBS and can be purchased by the patient from their local pharmacy.

Aloe Vera

Discourage its use in irritable bowel syndrome.

For Diarrhoea

Avoid sorbitol, an artificial sweetener found in sugar-free sweets (including chewing gum) and drinks, and in some diabetic and slimming products.

The following new drugs are expensive and as such they should be used only when really necessary. They can be highly effective and should be used in addition to laxatives rather than as an alternative. Patients frequently find they can reduce their use of laxatives with the regular use of these medications. See Joint Formulary 1.6.7 Other drugs used in constipation.

Pruclopride (a highly selective 5-HT4 agonist which stimulates gut motility) 1-2mg od. Headaches are a common side effect in the first few days of use and usually settle. NOTE: Not for use in patients with a history of migraine as can exacerbate severity and frequency of migraine headaches.

First Line Medication

Choose single or combination medication based on the predominant symptom(s).

Antispasmodics: These should be taken as required alongside dietary and lifestyle advice.

For constipation: Laxatives for constipation (but discourage use of lactulose as it causes bloating and flatulence). If laxatives fail, linaclotide is now licensed for constipation predominant IBS and has been used very successfully. It should not be used as a first line treatment, due to its high cost.

For diarrhoea: Offer loperamide as the first choice of anti-motility agent for diarrhoea*.

Anti-motility agents: Advise people how to adjust doses of laxative or anti-motility agent according to response, shown by stool consistency. The aim is a soft, well-formed stool (Bristol Stool Scale type 4).

*In certain situations the daily dose of loperamide required may exceed 16 mg. At the time this pathway was created this dose was an out of licensed dose. Informed consent should therefore be obtained and documented if it is used.

Second Line Medication

TCAs (tricyclic antidepressants)

Consider TCAs for their analgesic effect if first-line treatments do not help**.

Start at a low dose (10-20 mg equivalent of amitriptylline) at night and review regularly. Warn patients of the sedative side effects and dose can be titrated as tolerated.

SSRIs

If TCAs are ineffective, consider SSRIs**.

Take into account the possible side effects of TCAs and SSRIs. If prescribing these drugs for the first time, follow up after 4 weeks and then every 6–12 months. These medications may also help in those IBS sufferers who display symptoms of anxiety and or depression as well.

**At the time this pathway was created TCAs and SSRIs did not have UK marketing authorisation for the indications described. Informed consent should therefore be obtained and documented if they are used.

Agree follow-up with the person based on symptom responses to interventions. This should form part of the annual patient review.

Investigate or refer to secondary care if 'red flag' symptoms (above) appear during management and follow-up.

For people whose symptoms do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile (refractory irritable bowel syndrome), consider referring for:

Patients who do not respond to the above interventions may be considered to have ‘refractory IBS’. These patients may benefit from referral to the Refractory IBS Service, after faecal calprotectin screening (see above).

NICE DG11 (2013): “Many people with irritable bowel syndrome have unnecessary invasive hospital investigations before their condition is diagnosed. Using faecal calprotectin testing will mean most people with irritable bowel syndrome will be diagnosed without the need for these investigations.”

Practice Point

Please do not request faecal calprotectin as a routine test for the diagnosis of IBS. Only consider it in primary care when deciding to refer to the Refractory IBS Service.

Order the test via ICE, which will take you through a series of questions. Please note that:

Patients should not take any NSAID’s in the six weeks prior to collecting a sample.

The sample should be collected on a day when it can be delivered to the GP surgery or the laboratory on the same or next day. Samples taking more than 3 days to reach the laboratory will not be analysed and a repeat sample requested.

The test result will be available within 14 days of sample receipt in the laboratory.

The above pathway aims to provide the necessary guidance required to support the management of your patient, however if you would like to discuss a specific patient's case further please seek Advice & Guidance, via the NHS e-Referral Service, from GHNHSFT's Consultant Gastroenterologists as an alternative to making a referral. Advice & Guidance can be helpful in the following circumstances:

For their advice on a treatment plan and/or the ongoing management of a patient

For clarification (or advice) regarding a patient's test results

For advice on the appropriateness of a referral for a patient (e.g. whether to refer, or what the most appropriate alternative care pathway might be)

To identify the most clinically appropriate service to refer a patient into

Please view the resource for further information on using the Advice & Guidance service.

Patients with IBS are frequently over-investigated. The new low FODMAP diet can be highly successful in treating these patients. Non-responders may then need further investigation.

The Refractory IBS Service run by GHFT is a complete service for patients considered by their GP to have IBS but have failed to respond to appropriate primary care management, as outlined in this guidance. The clinic will assess these patients, manage them and further investigate them if it is indicated.

IBS sufferers who do not respond to usual management are also those patients who may end up being extensively investigated with colonoscopy and other tests, with some risk and with little benefit or relief of their symptoms.

Recent research has shown that a high proportion of such patients may respond well to a Low FODMAP diet. This diet is low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). These substances increase the delivery of readily fermentable substrates and water to the distal small intestine and the colon. This results in increased gas production which in turn produces luminal distension and pain. Reducing FODMAPs in these patient’s diets may significantly improve functional gastrointestinal symptoms.